It is fifty years since what most people think of as the first NHS inquiry – into failures in care at Ely Hospital in Cardiff. The inquiry was set up in 1967 to investigate allegations of ill-treatment, the abuse of patients and theft by staff at the long-stay psychiatric hospital.
On 27 March 1969, Richard Crossman, Secretary of State for Health and Social Services, made a statement to the House of Commons on the inquiry's report on Ely Hospital. Crossman said that the report was 'highly critical and will, I am sure, cause as deep concern to members as it does to me'. Other members termed it 'a very grave and disturbing report', and 'shocking and a tragedy for both patients and staff'.
It led, among other things, to the establishment of the Hospital Advisory Service, the first inspectorate for the NHS and in some ways the precursor of today's Care Quality Commission (CQC).
Inquiries serve many purposes – for example, establishing the facts of what happened, learning from these events, holding individuals or organisations to account, and providing an opportunity for catharsis and reconciliation for those involved.
Since Ely we have seen many more inquiries – Bristol, Shipman and Mid-Staffordshire, for example – and now, whenever something goes badly wrong in the NHS, there are loud calls for another inquiry. But do these inquiries work, and what real impact do they have? The Health Foundation recently hosted a meeting to discuss the many NHS inquiries that have taken place in the last fifty years, attended by people who were involved in them.
What have we learnt?
Inquiries are often key turning points in health policy, leading to important and major changes. For example:
- Ely (and other inquiries into scandals in long-stay hospitals in the 1970s) can be credited with helping to drive the closure of those institutions and the reshaping of care for people with learning difficulties and chronic mental illness.
- The Bristol inquiry in 2001 led to the creation of the Commission for Health Improvement, and contributed to the development of clinical governance in the NHS.
- The Shipman inquiry in 2005 drove fundamental reforms to health professions regulation.
- The mid-Staffordshire Hospital inquiries in 2010 and 2013 led to national changes to nurse staffing levels, reforms to hospital inspection, the new legal duty of candour, and reforms to protect whistle-blowers.
However, inquiries often seem to have similar findings, and make the same or similar recommendations over and over again. For example, the Ely inquiry found that 'it is immensely important to have a system whereby such people as nurses can make a case without fear of victimisation. This is the biggest single deficiency which Mr. Howe's investigation has exposed'. But the Bristol inquiry also found whistle-blowers had been victimised and marginalised, as did the Mid-Staffs inquiries, and it is not clear that the Freedom to Speak Up reforms introduced since then have really made much difference.
Equally, a number of inquiries have addressed the problem of how managers and leaders in the NHS are shown to be competent and are properly held to account. Bristol and Mid-Staffs both made similar recommendations about regulating managers or leaders, and the latter led to the introduction of the 'Fit and Proper Person Test', but the recent Kark review has criticised these arrangements and once again recommended forms of regulation which government seems unwilling to accept.
Perhaps we expect too much of inquiries and their reports, especially if we think they can solve intractable and complex problems in the NHS which have often persisted over many years. Inquiries may in fact not be a very effective or efficient way of investigating problems or learning lessons that can be applied to the wider NHS, and their recommendations deserve careful scrutiny, but not automatic acceptance.
The beginning, not the end
What’s more, we pay too little attention to what happens after an inquiry has reported. Although government generally produces an official response, indicating what it plans to do or has already done, there is no formal mechanism for monitoring or following up on this. Arguably, House of Commons select committees should be given a statutory responsibility to review and report on progress after an inquiry, for as long as it takes to see its recommendations through.
So next time something awful happens in the NHS – and we can be pretty sure there will be a next time – we should be both more cautious about accepting calls for an inquiry, and better at exploring and using alternative forms of investigation and learning. If an inquiry really is needed, those who lead it can learn a lot from previous inquiries about the process, how to make it work, and what should go into the report. But we also need to make sure that the report is not the end of the inquiry, but the start of a process of meaningful change and reform.
Martin Powell (@_HSMCentre) is Professor of Health and Social Policy at the University of Birmingham.
Kieran Walshe (@kieran_walshe) is Professor of Health Policy and Management at the University of Manchester.
The agenda and slide presentations from the NHS inquiries symposium are available on the University of Birmingham website. There is also a video from the symposium, short interviews with Martin Powell and Judith Smith, and a summary report of the day written by Nick Timmins.